PALLIATIVE CARE ELDERLY PATIENTS WITH SLEEPING DISORDERS ARE POORLY TREATED

Background: Sleep disorders are frequent in patients with advanced cancer receiving palliative-care, especially in elderly patients (1). Sleep disorders during palliative-care may be related with anxiety, opioids related central-sleep apnoea or corticoids therapy between others (2). Our aim was to quantify the effectiveness of hypnotic medication in the sleep quality in advanced cancer receiving palliative-care elderly patients. Material and methods: A descriptive cross-sectional study was conducted in elderly patients with advanced cancer receiving palliative-care exploring their sleep quantity and quality (approved by Local Ethical Committee). Patients who were in our palliative care program and didn´t have any exclusion criteria: Age below 60 years, with ability to communicate effectively, and without cognitive failure and/or delirium, and/or psychotic illness. The Pittsburgh Sleep Quality Index (PSQI) questionnaire and EVA scales were used to measured sleep quality and pain and anxiety levels. Patient under corticoids treatment were compared with other non-sleep disorders risky treatment. Results are expressed as mean ± sem. and were compared by Student t test and ANOVA test followed by Bonferroni post-test. Results: Patients, N=138, 63.8% male, aged 70.9±1.1 years old with diagnostic of 28.3% gastro-intestinal, 15.9% mama/gynaecological , 13% pulmonary, 12.3% urinary, 6.5% liver, 4.3% central nervous system, 1.4% pancreatic, and 18.1% others types of terminal cancer were enrolled. Patients were treated with no oncologic treatment (78.3%), chemotherapy (12.3%), radiotherapy (5.1%), hormone therapy (3.6%), or immunotherapy (0.7%). 54.3% were treated with corticoids vs. 20.3% under other sleep disorders risky treatment and 25.4% with no treatment. The sleep disturbances prevalence were 81.2% in the total population and 90.4% in patients treated with corticoids (p<0.05). However a 54.3% of the patients received benzodiazepines, zolpidem or chlormethiazole. 65.2% of the patients need more than three times rescue hypnotic medication during the last week. Bad sleeper showed significantly higher intensity of pain, asthenia, sadness, anxiety, nausea, dyspnea and discomfort. Discussion: Sleep disorders may be primary or, more commonly, a secondary symptom of the advancing disease process. Multiple pharmacologic and non-pharmacologic interventions may be used for the management of sleep disturbances in palliative medicine. However, many patients do not seek medical attention for sleep disturbances, and health care providers tend to under-diagnose this condition and under-treat it when diagnosed, thus missing an opportunity to improve the quality of life of patients already suffering from the burden of terminal disease. The diversity of patients under palliative care makes management of sleep disorders particularly challenging and highly needed to be individualized. Conclusion. Elderly patients with advanced cancer subjected to palliative care received insufficient hypnotic medication especially under corticoids co-treatment. References: (1) Sateia MJ and Lang BJ. 2008. Curr Oncol Rep 10(4):309-18. (2) Yennurajalingam S et al. 2011. J Pain Symptom Manage 41(1):49-56.University of Malaga. Campus of International Excellence Andalucia Tech

Insuficiente control de la calidad de sueño en pacientes con cáncer avanzado en cuidados paliativos

Introducción: Los trastornos del sueño son frecuentes en los pacientes con cáncer avanzado en atención paliativa. Objetivos: Cuantificar la cantidad-calidad del sueño en pacientes con cáncer avanzado en cuidados paliativos. Material y Métodos: Estudio descriptivo, transversal en pacientes >60 años. Se determinó la cantidad-calidad del sueño, dolor y ansiedad utilizando el cuestionario Pittsburgh Sleep Quality Index y escalas EVA. Resultados: Se incluyeron 138 pacientes, 63,8% hombres, con 70,9±1,1 años, con cáncer terminal: gastrointestinal 28,3%, mama-ginecológico 15,9%, pulmonar 13%, urinario 12,3%, hígado 6,5%, sistema nervioso central 4,3%, páncreas 1,4%, y otros un 18,1%. Los pacientes fueron tratados con quimioterapia 12,3%, radioterapia 5,1%, terapia hormonal 3,6%, inmunoterapia 0,7% y sin tratamiento oncológico 78,3%. El 81,2% presentó trastornos del sueño. Sólo el 54,3% recibió benzodiacepinas, zolpidem o clormetiazol. El 65,2% de los pacientes precisó más de tres veces medicación hipnótica de rescate durante la última semana. Los pacientes con peor calidad de sueño mostraron significativamente mayor intensidad del dolor, astenia, tristeza, ansiedad, náuseas, disnea y malestar general. Discusión: Los trastornos del sueño pueden ser primarios o, más comúnmente, un síntoma secundario del proceso de la enfermedad avanzada grave. Su abordaje farmacológico y las intervenciones no farmacológicas son múltiples y se pueden usar para la gestión de los trastornos del sueño en la medicina paliativa. Muchos pacientes en esta circunstancia no buscan atención médica para los trastornos del sueño, y los profesionales de atención de la salud tienden a infra-diagnosticar e infra-tratar esta complicación cuando se diagnostica, perdiendo así una oportunidad para mejorar la calidad de vida de los pacientes que ya sufren de la carga de la enfermedad terminal. La diversidad de los pacientes bajo cuidados paliativos hace que la gestión de los trastornos del sueño sea particularmente muy difícil deba ser individualizada. Conclusión: Los pacientes bajo cuidados paliativos recibieron medicación hipnótica insuficiente.Ayuda del Plan Propio de Investigación de la UMA. Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Inpatients hyperglycaemic control by basal/bolus rapid-acting insulin injection.

Este artículo fue publicado en: Basic & Clinical Pharmacology & Toxicology, vol 115, Issue Supplement s1: pp 243.Inpatients hyperglycaemic control by basal/bolus rapid-acting insulin injection. M Vazquez-Marquez, I Bellido, Gomez-Huelgas R, Lopez-Carmona MD, Jansen S, Sobrino B, Chaves M, Martin-Gallardo P, Garcia-Fernandez C, Bernal-Lopez MR, E Blanco, EI Marquez, J de Pablo, JA Garcia-Arnes, A Gomez-Luque   Background: Prandial bolus rapid-acting insulin injection based on sliding-scale insulin glycaemia control is an useful DM inpatients' treatment which increases hyper and hypoglycaemic events. Efficiency and safety of new therapeutic algorithm of glucose management using scheduled basal/bolus rapid-acting insulin injection in glycaemic control and prescribing habits of inpatients with hyperglycaemia were evaluated and compared to sliding-scale insulin glycaemia control. Methods: Pre-post intervention study in consecutively admitted inpatients with DM and with no previous diagnosis of DM inpatients plus diagnostic criteria at admission (some blood samples with glycaemia >126 mg/dL or hyperglycaemia symptoms plus one sample with glycaemia >200mg/dL) was done at 3 breakpoints pre, and one and three years post-intervention and was compared to classical sliding scale insulin glycaemia control. Epidemiological, clinical (DM type, household income, clinical history, reason for admission), analytical data, treatments, and degree of glycaemic control (average of capillary levels pre-prandial in the last 72 h) were collected. Pre-intervention monitoring data were compared with post-intervention follow-up data.   Results: 1151 inpatients were included (58.6% male, 61.1±17 years aged, 84.4% type II DM). The prevalences of stable-hyperglycaemia preintervention and 1 and 3 years postintervention were 24.8%, 22.1% and 26.4%, respectivelity. The percentage of patients subjected to the new glycaemic control algorithm has increased progressively from 11% to 52.8% and 62.9% along the follow-up. No significant changes were detected in the last 72 h glycaemia absolutes values. However an increased percentages of good glycaemic control (defined as glycaemia between 100-140 mg/dL) close to 30%, 31.3% and 38.6% (p<0.05) were recorded preintervention and 1 and 3 years postintervention. One year post-intervention hypoglycaemia events were reduced comparing to pre-intervention values (6.98% vs. 13.5%, -50%, p<0.05). Unfortunately it returned to previous values after three years of follow-up (12.1%). Hyperglycaemia deficient control was mainly associated to sliding scale insulin control based treatment during all the follow-up.  Conclusion: The scheduled basal/bolus rapid-acting insulin injection in glycaemic control of inpatients with hyperglycaemia was more effective, safety than the classical sliding-scale insulin glycaemia control. However greater disclosure and annual reinforcements of this new therapeutic protocol are necessary for improving outcomes and allow prescription habits changes.  University of Malaga. Campus of international excellence Andalucia Tech

Risk and protective factors for release in outpatients with schizophrenia

eposterWe aim to determine risk and protective factors influencing relapse incidence in outpatient with schizophrenia. A longitudinal, observational study was done with outpatients with schizophrenia (F20) or schizoaffective disorder (F25)(DMS-IV and ICD-10), without hospitalization during the previous 6 months. The patients were consecutively included into the study to received oral (O-A) or long-acting injectable (depot-A) antipsychotics. Clinical stage evolution, compliance, efficacy and safety assessments (including PANSS, CGI-SSI, hospitalization rates, and adverse events) were recorded before and after 6 and 12 months of treatment. Results: 60 outpatients (aged 34.5±8.9, male 73%), 75% schizophrenia and 25% schizoaffective disorder diagnosis, 68.3% fewer than 15 years of schizophrenia evolution, 76.7% fewer than 5 times previous hospitalizations were treated with O-A (41.7%) or depot-A (58.3%) antipsychotics for at least one year. Depot-A treated patients showed a significant higher compliance compared to O-A patients during the all following time, lower PANSS (total, positive and negative) scores and CGI-SSI score (p<0.01), and a delayed relapse incidence and re-hospitalization to more than 1 year in the 48% of patients (relapse % depot/% oral) after 6 months 22.9%/52.0%, and after 12 months 48.6%/4.0%. Conclusion: There were protective factors which delayed relapse incidence in schizophrenia: Use of sustained-release preparations, family support. There were risk factors for occurrence of relapse in schizophrenia: cocaine, heroin and alcohol consumption, absence of family support, greater severity of patients assessed through CGI-SI, male sex, age older than 25 years and long-term evolution of the disorder.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Avatars and Cartoons reduce anxiety in pediatric inpatients

Avatars and Cartoons reduce anxiety in pediatric inpatients I Bellido1, MV Bellido2, A Gomez-Luque3. 1University of Malaga, Pharmacology and Clinical Therapeutics, Spain, 2Regional University Hospital, Malaga, Surgery Service, Spain, 3Virgen de la Victoria University Hospital, Malaga, Anaesthesia Service, Spain Background and aim: Pain induces fear, stress and anxiety in young children. Avatars and cartoons explaining analgesic and sedative drugs administration routes may reduce children’s anxiety in young children. We quantify the possible antianxiety effect of avatars and cartoons explaining analgesic and sedative drug’s administration routes to inpatients children. Methods: A prospective, aleatorized, controlled study (blinded for the analyser) in inpatients children (< 6 years old) was done. Clinical stage, diagnostic, surgery, anaesthesia and all treatment procedures were recorded. Anxiety (STAIC test) was recorded before and 5 h and 24 h after drugs administration. A 15 minutes movie with avatars and cartoons explaining how the analgesic and sedative drugs were going to be administered was use in 120 children (movie group) and was compared to other group that could not see the movie (control group n=120). Results: Children, N=240, aged 3-6 years, 4.5±1 years old, 55% male, treated in emergency 50%, surgery (31.3%) and intensities care unit (18.8%) were enrolled. The drugs routes administration were oral (25%), intramuscular (29.6%), intravenous (39.6%), inhalatory (3.8%), others (2.1%). Children saw part or the full movie an average of 5.2±2.1 times. At 24 h of follow-up anxiety was higher in control than in movie group (8.5±3 vs. 4.3±1.6, p<0.05, Student t test). Children of the control group wept, complained, and called their parents during more time than movie group. Conclusion: The use of avatars and cartoons to explain analgesics and sedative drugs routes administration to inpatients young children reduced children’s anxiety.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Flipped classroom based on objective structured clinical examinations analysis by undergraduate students of Pharmacology course from the Podiatry Degree improve their learning and assessment communication skills about medicines

Comunicación cartel con defensa oralWe aim to evaluate the impact of the individual and in-group analysis of OSCEs (filmed by other students) looking for correct and incorrect behaviours and contents in their learning of pharmacology. Summary of work and outcomes: A 5-year prospective study in which students of Pharmacology course from the Podiatry Degree analysed filmed OSCEs individually and in a group in a flipped classroom. Each group (max 5 students) analysed along 1 week a filmed OSCE, prepare a summary of correct and incorrect items related to clinical events, medicines uses, and people behaviours. The students presented their analysis results to the rest of the class. After each presentation, the other students of the class were encouraged to ask questions and after that, the students voluntarily answered a satisfaction survey. Result and Discussion: 405 students, 65.2% female, 20±5.3 years old were included. Students spend 13.4±5.4 h on making the filmed-OSCE analysis. The percentage of students satisfied with this way of studying pharmacology was 96.5%. OSCEs analysis by students increased their percentage of success in the final assessment in both OSCEs-related and OSCEs-non-related questions (+18.5% and +10.1%). Conclusion: Filmed Objective Structured Clinical Examinations analysis by undergraduate students on the Pharmacology course of Podiatry Degree improved their knowledge about medicines use and their communication skills during the assessment.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Postoperative pain and morphine consumption after ultrasound-guided femoral and sciatic combined nerve block versus neurostimulation for femoral and sciatic combined nerve block or neurostimulation for femoral nerve block in primary elective total knee arthroplasty.

Abstract Congreso XXXVII National Meeting of the Spanish Society of Pharmacology with guest society: The British Pharmacological SocietyBackground and Aims: Total knee arthroplasty injuries are extremely painful and merit prompt attention to adequate postoperative analgesia. We aim to compare femoral and sciatic ultrasound-guided combined nerve block vs. neurostimulation for femoral and sciatic combined nerve block or for femoral nerve block in postoperative pain in primary elective total knee prosthesis. Summary of work and outcomes: A three arms, prospective longitudinal study of patients having primary elective unilateral knee prosthesis and randomly assigned to catheter insertion guided by ultrasound or neurostimulation was done: 1) Ultrasound-guided femoral and sciatic combined nerve block (USFSCN) (N=15); 2) Neurostimulation for femoral and sciatic combined nerve block (NSFSCN) (N=17); 3) Neurostimulation for femoral nerve block (NSFN) (N=11). Total analgesia (morphine) consumption after 48 hours was the primary endpoint. The postoperative pain intensity (visual analogue pain scale (VAS)) at post-anaesthetic recovery unit (PARU), 6, 24, 48 h, and during movement and postoperative complications were secondary outcomes. Results and discussion: 43 patients (68.3±8 years old, 77% female) subjected to elective unilateral knee prosthesis were enrolled. There were no differences in the demographic, anaesthetic and surgical variables between groups. Pain intensity was lower in the USFSCN group compared with NSFSCN and NSFN during the first 48 h post-surgery (% of intense pain at PARU/6h/24h/48h): USFSCN 0.8/1.4/3.2/1.6; NSFSCN 5.6/8.3/7.5/3; NSFN 7.2/5.3/6.4/5.4. The average consumption of morphine within 48 h after surgery was similar in the groups USFSCN and NSFSCN (3 mg vs. 3.11 mg), and significantly lower than NSFN (4.19 mg) (p<0.05). And the number of complications was significantly lower in the USFSCN group compared with NSFSCN and NSFN during the first 48 h of postoperative. Conclusion: Ultrasound-guided femoral and sciatic combined nerve block presented better analgesia and was more safety than neurostimulation for femoral and sciatic combined nerve block or for femoral nerve block in primary elective total knee arthroplasty.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Underuse of indicated medications in elderly

Introduction: Treatment omissions are very important to value the quality of pharmacological therapy. In fact, suboptimal prescribing has been defined as overuse (polypharmacy), inappropriate prescribing (drug whose risks are greater than the benefits in older adults) and underuse of indicated medications. This omission of drug therapy may be linked to certain health outcomes in older patients, such as, for instance, the greater risk of cardiovascular events and mortality Material and methods: A cross-sectional study was performed. The study population comprised 407 community-dwelling residents over the age of 65 on Lanzarote (Canary Islands, Spain), where there are 15 primary healthcare centres. Data recorded included socio-demographic characteristics, clinical status, functional and cognitive assessment, and complete information about drugs intake. Potential prescribing omissions (PPO) were evaluated according to Screening Tool to Alert doctors to Right Treatment (START). Results: A total of 1844 medications were prescribed to the patients included in our study (median number per patient: 4.5 drugs; range: 0-14: polypharmacy prevalence: 45%). Omeprazole was the most frequently used drug followed by aspirin, furosemide and enalapril. START identified PPO in 170 (41.8%) subjects. Sixteen of the 22 START criteria (72.7%) were used to identify these PPO. The endocrine system accounted for over half the omissions (51.8%), followed by the cardiovascular system (26.7%), where the main omission was anticoagulants in the presence of chronic atrial fibrillation. Multiple logistic regression analysis revealed that the risk of PPO increased by 60% for every additional point in the Charlson Comorbidity Index (OR 1.60, 95% CI 1.35-1.91). Increasing numbers of medications also independently predicted the odds of at least one PPO according to START criteria (OR 2.19, 95% CI 1.36-3.55). Conclusions: Our findings show high rates of polypharmacy and PPO, as well as a clear relationship between these two concepts.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tec

Factores de riesgo cardiovascular en pacientes ancianos diabéticos que acuden a urgencias

Comunicación en formato cartel con defensa oralOBJETIVO: Son escasas las evidencias clínicas disponibles sobre los factores de riesgo cardiovascular en los pacientes ancianos diabéticos. Nuestro objetivo fue determinar los principales factores de riesgo cardiovasculares de los pacientes diabéticos ancianos en urgencias. MATERIAL Y MÉTODOS: Diseño, ámbito de realización y marco o nivel de atención sanitaria, criterios de selección, número de sujetos incluidos, número de sujetos que responden y abandonos, intervenciones (si procede), variables y métodos de evaluación de la respuesta. Análisis estadístico, limitaciones, aspectos ético-legales. Estudio descriptivo observacional, retrospectivo, transversal y quasiexperimental en pacientes diabéticos ≥65 años de ambos géneros que acudieron a urgencias durante 1 año. Criterios inclusión: tratamiento hipoglucemiante, HbA1c >6,5% durante el año previo, sin comorbilidades graves. RESULTADOS: Se han incluido 146 pacientes diabéticos tipo 2, 39,7% hombres,76,4±7,2 años. Un 24,2% presentó síndromes geriátricos, 93,2% presentó comorbilidades asociadas, 22,6% presentó afectación renal, 89% utilizaba normoglucemiantes orales (hombres 91,4% >mujeres 86,4%): Biguanidas 78,8%, IDPP-4 22,5%, sulfonilureas 2ª-generación 18,5%. El 61% tratado con metformina 850 mg, seguido de gliclazida 30 mg 13% y metformina 1 g 11%. Tratamientos para comorbilidades más usados: Antihipertensivos 88,40%, normocolesterolemiantes 58,90%, antiagregantes 56,80%, benzodiacepinas 45,90%, calcioantagonistas 37,7%, betabloqueantes adrenérgicos 37%, antidepresivos 26,70% y opiáceos 24%. CONCLUSION: Ser mujer, tener mayor edad, más comorbilidades y de ellas hipertensión arterial y fibrilación auricular se relacionó con el mayor número de ictus isquémicos y el mayor tiempo de evolución del accidente isquémico transitorio. La prevalencia de reacciones adversas a medicamentos fue el doble en las mujeres que en los hombres y mayor en los pacientes menores de 80 años.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech

Clinical simulation in an objective structured clinical examinations scenario active learning improved communication skills and assessment of psychopharmacology student of medicine degree.

Abstrac congresoObjective: Objective Structured Clinical Examinations are versatile multipurpose evaluative tools utilized to assess health care professionals in a clinical setting including communication skills and ability to handle unpredictable patient behavior. Clinical simulation-based training is a widespread strategy to improve health-care quality. We aim to evaluate the impact of clinical simulation (CS) performed in an objective structured clinical examinations (OSCEs) scenario designee and perform by student on arguing, planning capacities, communication skills and learning of therapeutics in undergraduate students from Psychopharmacology course of the Medicine Degree. Methods: A two-year study in which undergraduate students from Medicine degree’s Psychopharmacology course were trained using CS in an OSCEs scenario designee and perform by students, including: Explain a treatment, convince of the need to follow a treatment, warn of possible adverse reactions, report a death due to an medicine adverse reaction. Data from students of previous courses who never run CS-OSCEs were use as control. Results: Students from Psychopharmacology course, N=331, 60.7% female, 21±4.5 years old, were enrolled. The average time spent by students in making CS-OSCE training was 12.6±3.1 h. The percentage of students that were satisfied with this way of active learning was 92.5%. CS-OSCE student group showed an increased number of correct answer to the questions of the assessment with respect to non-CS-OSCE trained students +26.9% hits (P < 0.05). Conclusion: Clinical simulation active learning in an objective structured clinical examinations scenario designed and performed by student of Psychopharmacology of the Medicine Degree improved their communication skills and knowledge of medicines.Universidad de Málaga. Campus de Excelencia Internacional Andalucía Tech